The effects of enteral nutrition in the bowel preparation in patients with diabetes mellitus

Xiu-Li OU, Yu-Zhen CHEN, Min ZHANG,Li-Zhen LYU

1Department of Nursing, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, Jiangmen, Guangdong Province, China; 2Department of Endocrinology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, Jiangmen, Guangdong Province, China

ABSTRACT

Objective: The objective of the study was to investigate the effect of enteral nutrients in diabetic patients with fibrocolonoscopy.

Materials and Methods: A total of 58 diabetic patients undergoing fibrocolonoscopy from January 2017 to December 2017 were included as the traditional bowel preparation group.The patients took traditional semi-flow diet and catharsis as intestinal preparation and were given health education.Sixty patients treated with fibrocolonoscopy from July to December in 2018 were included as the enteral nutrition group and received enteral nutrients and catharsis as intestinal preparation and were given modified health education.The incidence of hypoglycemia during intestinal preparation was compared between the two groups.

Results: A total of 20 (34.48%) patients in the traditional bowel preparation group had hypoglycemia (including asymptomatic hypoglycemia) during bowel preparation, with the total frequency of 40.The blood glucose level fluctuated between 1.7 and 3.9 mmol/L.Only five patients in the enteral nutrition group had hypoglycemia (including asymptomatic hypoglycemia) during bowel preparation.The incidence of hypoglycemia was lower in the enteral nutrition group than that in the traditional bowel preparation group (χ2 = 4.937, P = 0.026).

Conclusion: The enteral nutrients as diet for fibrocolonoscopy bowel preparation and strengthening health education could reduce the incidence of hypoglycemia in patients with diabetes during bowel preparation and ensure patient safety.

Keywords: Bowel preparation, colonoscopy, diabetes mellitus, enteral nutrition, hypoglycemia

INTRODUCTION

Fibrocolonoscopy is a common clinical examination method.In order to obtain a clean examination field, bowel preparation is performed before the colonoscopy.During bowel preparation, patients, especially diabetes patients, might develop hypoglycemia with or without clinical symptoms due to the effects of fasting, catharsis, age, and so on.Research showed that the incidence of hypoglycemia in elderly diabetic patients undergoing colonoscopy before, during, or after the examination is 1.5435%.[1]Hence, the safety of diabetic patients during bowel preparation had attracted attention.To avoid the symptoms of hypoglycemia, diabetic patients had to tackle the problem by taking appropriate amount of carbohydrates and adjusting the dosage of hypoglycemic drugs.However, there were few guidelines on the dosage of catharsis and hypoglycemic drugs and diet to follow.[2]Based on this situation, we tried to adjust the intestinal preparation plan to reduce the incidence of hypoglycemia during intestinal preparation of hospitalized diabetic patients and ensure patient safety.

MATERIALS AND METHODS

This study was approved by the Ethics Committee of Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University.

Patients

Diabetic patients who were hospitalized in the endocrinology department of our hospital, received fibrocolonoscopy, whose plasma glucose in the oral glucose tolerance test 2 h test was over 11.1 mmol/L, aged ≥18 years, and treated with insulin were included in the study.Fifty-eight hospitalized patients, from January 1, 2017, to December 31, 2017, were included as the traditional bowel preparation group, including 34 males (58.6%) and 24 females (41.4%).The age of the patients was between 31 and 72 years, with an average age of 53.66 ± 10.58 years.Moreover, sixty patients, from July 1, 2018, to December 31, 2018, were included as the enteral nutrition group, including 38 males (63.3%) and 22 females (36.7%).The age ranges from 36 to 69 years, with an average age of 52.77 ± 9.59 years.There were no statistical differences between the two groups in terms of gender, age, education, comorbidities, and blood glucose level (P＞ 0.05).

Methods

Bayer’s blood glucose meter (7600P), test strips, and quality control products were used.The quality control of the blood glucose meter followed the quality control procedure of the instrument of our hospital.The quality control liquid was used for quality control once a day, and the venous blood glucose was compared every 6 months.

Blood glucose monitoring was performed at four fixed time points for the patients each day: fasting, before lunch, before dinner, and before bedtime.Immediately, fingertip blood glucose was monitored when patients had hypoglycemia symptoms such as palpitations, sweating, hand shaking, and hunger.Hypoglycemia was defined as a blood glucose value of ≤3.9 mmol/L.If the patients had one or more episodes of hypoglycemia occurred during bowel preparation, he would be recorded hypoglycemia one.

Intervention

The traditional bowel preparation group

Before receiving the colonoscopy, the patient would have a semi-fluid diet 1 day in advance, such as porridge and soup.And, the patient was not recommended to take fiber-rich food, such as rice, vegetables and fruits, and dusty and indigestible food.According to the colonoscopy appointment time, the patient took laxatives at 8:00 p.m.before the test (the appointment time was in the morning), or 8:00 a.m.on the day of the test (the appointment time was in the afternoon).Patients with chronic constipation would be given half dose of laxative 2 days prior to the examination, and given the other half of laxativeon the day prior to the examination and drank sufficient water according to the doctor’s advice, so as to obtain a good intestinal preparation effect.Nurses provided health education and checked the examination time and implemented the timely treatment when the patient had hypoglycemia.During bowel preparation, the patient received adjusted insulin treatment as prescribed by doctor.

The enteral nutrition group

The dietary plan would be adjusted.Patients with smooth stools would take intestinal nutrients (Ensure®) on the day before the test.On that day, instead of taking semi-fluid diet, they had three meals of Ensure: six spoons for breakfast (about 200-250 Kcal) and 12 spoons for lunch and dinner each (about 400-500 Kcal).Moreover, they would have extra 3-6 spoons of enteral nutrients (about 100-250 Kcal) if their blood glucose below 8 mmol/L (after meals).Nurses received training course by nutritionists and diabetes specialists so that they would have the ability to uniform and standardize dietary education during bowel preparation for the patients.The training course included the knowledge about nutrition, blood glucose monitoring, and colonoscopy preparation.The patient was given educational materials.Health education would be provided by the nurse on the day the colonoscopy was issued, the 1stday after the appointment, and the day of the examination.The cathartic procedure was the same as that of the traditional bowel preparation group.Furthermore, the nurses provided health education and checked the examination time and implemented the timely treatment when the patient had hypoglycemia.During bowel preparation, the patient received adjusted insulin treatment as prescribed by doctor.

Statistical analysis

All data were analyzed by SPSS 19.0 software.Continuous data were analyzed byt-test, and categorical data were analyzed by Chi-squared test, andP＜ 0.05 was considered statistically significant.

RESULTS

The incidence of hypoglycemia during bowel preparation

Of the 58 patients in the traditional bowel preparation group, 20 patients (34.48%) developed hypoglycemia (including asymptomatic hypoglycemia) during the bowel preparation period, and a total of forty hypoglycemia occurred.The blood glucose level of these patients fluctuated from 1.7 mmol/L to 3.9 mmol/L.Of the sixty patients in the enteral nutrition group, only five had hypoglycemia (including asymptomatic hypoglycemia) during bowel preparation, which accounted for 8.33% of hypoglycemia.The incidence of hypoglycemia was lower in the enteral nutrition group than in the traditional bowel preparation group (χ2=4.937,P= 0.026) [Table 1].

Table 1: The incidence of hypoglycemia during bowel preparation, n (%)

DISCUSSION

Bowel preparation refers to the method of cleaning the bowel by oral administration or enema.It is widely used in bowel surgery, colonoscopy, capsule endoscopy, and imaging tests (e.g., bowel computed tomography).Ideal bowel preparation for colonoscopy should have good patient compliance and lead to little discomfort, and would not cause water and electrolyte disturbances, etc.[3,4]However, it also would cause some complications.Some studies had shown that patients with diabetes might face risks due to hypoglycemia or asymptomatic hypoglycemia during bowel preparation.[1,5]Hence, it is important to ensure the safety during the bowel preparation period.Current studies mainly focused on how to adjust patients’ diet or laxative plan to reduce the incidence of hypoglycemia and ensure satisfied bowel preparation effect.[1,2,5]

AlthoughChineseBowelPreparationGuideforGastrointestinalEndoscopy(Draft) recommends that patients start a low-fiber diet 1 day before endoscopic examination could improve the cleanliness of intestinal preparation, it is not recommended to have fasting beyond 24 h before endoscopic examination.[6]Furthermore, it did not explicitly point out the dietary restrictions in the intestinal preparation of diabetic patients.Hence, there were no uniform dietary guidelines for diabetic patients.[2]According to relevant guidelines and research, we mainly adjusted the patient’s dietary process in the preparation period, replacing the traditional low-fiber diet with a basic enteral nutrition formula to provide nutritional sources and facilitate clinical operations.In this study, patients who took a half-flow diet as an intestinal preparation diet had a higher risk of hypoglycemia (34.48%), similar to the results of other studies.Ensure, as a basic enteral nutrition formula, has a calorie distribution of 14.2% protein, 54.0% carbohydrates, and 31.8% fat, and could be completely absorbed.Hence, it could be accurately measured for the calorie intake.Furthermore, based on the calorie calculation, doctors could accurately adjust the insulin treatment dose of the diabetic patient without considering the diversity of calorie intake in low-fiber diet, to help patient to maintain stable blood glucose levels.Thus, it was recommended by theChineseDiabetesMedicalNutritionTreatmentGuideline(2013).[7]In this research, it was proved that patients who had enteral nutrition powder had lower incidence of hypoglycemia during intestinal preparation than patients had half-flow diet.In addition, in the routine blood glucose monitoring of patients, meals were added when the blood glucose after meal was ＜8 mmol/L, which increases the calorie supply by 100-250 Kcal, and this has a certain positive effect on the risk prevention of hypoglycemia.In addition, compared with the 3-day diet preparation in other studies, the 1-day intestinal preparation in this study followed the guidelines and literature recommendations[5,8]and could meet the ideal intestinal needs.

The guidelines also pointed out that the patient’s intestinal preparation and health education were particularly important.[5]Because of the complexity of the bowel preparation process, sufficient education before bowel preparation could improve patient compliance with bowel cleansers.In the previous process of our hospital, patients mainly used to be verbally educated.Considering the patient’s age, acceptance, and other factors, we modified the patterns and times of education.The enteral nutrition group was given verbal education and reading materials, and was spent more time in educating.In this way, it helped patients better accept the details of bowel preparation and strictly follow dietary guidelines.

CONCLUSION

In the intestinal preparation of diabetic patients, the use of enteral nutrients to replace the semi-fluid diet is conducive.By accurately calculating calorie intake of the patients and strengthening health education, it could effectively reduce the risk of hypoglycemia.In future studies, the sample size could be enlarged, and the intestinal cleanliness of patients could be assessed at the same time to verify the effect of enteral nutrients in the bowel preparation for diabetic patients with fibrocolonoscopy.

Declaration of patient consent

The informed consent has been obtained from all patients included in this study.In the form, the patients have given their consent for clinical information to be reported in the journal.The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.